Provider Demographics
NPI:1346410131
Name:MORTENSEN, MICHAEL D (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2324
Mailing Address - Country:US
Mailing Address - Phone:801-492-1701
Mailing Address - Fax:801-492-1703
Practice Address - Street 1:8 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2324
Practice Address - Country:US
Practice Address - Phone:801-492-1701
Practice Address - Fax:801-492-1703
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6159168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor